Werner Schupp, Julia Haubrich, Kenji Ojima, Chisato Dan ... · dibular molar distalization. Example 1 (Team Schupp/Haubrich) Diagnosis The 26-year old female patient presented herself

37Journal of Aligner Orthodontics 2017;1(1):37–57

CASE REPORT

Werner Schupp, Julia Haubrich, Kenji Ojima, Chisato Dan, Yuriko Kumagai, Sumimasa Otsuka

Accelerated Invisalign treatment of patients with a skeletal Class III

Werner Schupp

Werner Schupp, Dr. med. dentFachpraxis für Kieferorthopädie, Haupstraße 50, 50996, Köln

Julia Haubrich, Dr. med. dent.Fachpraxis für Kieferorthopädie, c/o Schupp, Hauptstraße 50, 50996 Köln

Kenji Oima, D.D.S2-39-5-2F Kataoka Build. Hongo, Bunkyo-Ku/Tokyo/Japan

Chisato Dan, D.D.S2-39-5-2F Kataoka Build. Hongo, Bunkyo-Ku/Tokyo/Japan

Yuriko Kumagai, D.D.S2-39-5-2F Kataoka Build. Hongo, Bunkyo-Ku/Tokyo/Japan

Sumimasa Otsuka, D.D.S, PhD.1-22-5-3F Nakazawa Build. Higashi Gotanda/Shinagawa-ku/Tokyo/Japan

Correspondence to: Dr Werner Schupp E-Mail: [email protected]

Key words accelerated aligner treatment, aligner treatment, Class III treatment, distalization in the mandibular arch, Invisalign, skeletal anchorage

In skeletal Class III patients, severe disharmony of the maxil-la and mandible is corrected surgically. However, there is a wide variety of criteria for this surgery and practitioners must often select a non-surgical treatment if requested by the patient. In such a situation, in patients where anterior crowding is accompanied by anterior crossbite, a common treatment involves improvement through mandibular pre-molar extraction and lingual inclination of the mandib-ular incisors1. In addition, expansion of the maxillary dental arch is an e ective technique. However, from an aesthetic point of view, patients occasionally choose a multi-bracket appliance, even on the lingual side, in favour of a removable device. Just a few years ago, when compared with mul-ti-bracket treatments, aligners usually required longer treat-ment times and the lack of precise control of axial movement

led some to suggest that cases treated with aligners must be chosen carefully2.Since 2010, when Schupp et al presented a successful treat-ment of class II relationship using the Invisalign system with non-extraction, but molar distalization3, more and more practices have begun to treat patients previously believed to need extraction with a non-extraction distalization ap-proach4-6. Compared with case reports on the distalization of maxillary molars, the number of mandibular-molar dis-talization case reports is lower7, and clear data (molar dis-talization distance limits) have not yet been presented. his article reports two patient examples. In the rst, we

used the Invisalign technique only, changing the aligners every 7 days. he second patient example shows a non-sur-gical treatment of a severe skeletal Class III using a combina-tion of aligners with temporary anchorage advices (TADs)8 and AcceleDent9-11 (OrthoAccel Technologies, Inc, 6575 West oop South, SA) obtaining more e ective and faster man-

dibular molar distalization.

Example 1 (Team Schupp/Haubrich)

DiagnosisThe 26-year old female patient presented herself with a skeletal Class III relationship, crowding in the maxillary and mandibular arches, with restricted maxillary arch forms and retrally inclined maxillary and mandibular

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SCHUPP ET AL

incisors. The mandibular midline was shifted to the right. As shown in Figure 2, the patient had severe incisor contacts on the lateral and frontal incisors. The patient’s mouth opening was 48 mm without deviation. The manual exam-ination of the TMJ did not show clicking, crepitation or pain with palpation in the porus acusticus externus. The extraoral pictures demonstrate a concave face with a prognathic chin. The lower lip is protrusive to the upper lip. From the anterior view the face is symmetrical, with the chin in the facial midline.

Treatment goalThe patient is a professional singer and asked for non-sur-gical treatment. The orthodontic treatment plan included alignment of the arches, distalization of the mandibular molars, premolars and canines into a class I relationship and creating space for alignment of mandibular anteriors to obtain a physiological overjet and overbite, as well as midline correction. The maxillary arch needed expansion and the maxillary incisors were planned to torque.

igs a to i Extra- and intraoral situation at the start of treatment planning with Class III relationship, shifted midlines, crowding in the maxillary and mandibular anterior arch. The orthopantomogram shows no pathologies.

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Journal of Aligner Orthodontics 2017;1(1):37–57 39

ACCELERATED INVISALIGN TREATMENT OF PATIENTS WITH A SKELETAL CLASS III

Treatment alternativesObviously, an orthognathic surgical procedure would have been possible for this patient, and bimaxillary surgery would have altered her pro le into a standard aspect. If the patient had desired such a procedure, the “Surgery First” procedure proposed by Sugawara12 would have been an option. Another alternative would be extraction therapy in the mandible.

Because of the patient’s career as a professional singer, a multi-bracket appliance was not an alternative either lin-

gually or buccally. The patient did not want to change her extraoral appearance; a xed appliance was not possible due to her profession, so the only possible alternative was aligner therapy.

Treatment progressionThe treatment was planned with the Invisalign technique, including Class III elastics for anchorage on mandibular ca-nines to maxillary rst molars. The treatment consisted of 30 aligners in the maxillary and 60 aligners in the mandibular

ig Initial scan with occlusal contact points on all teeth with malocclusion contacts on all incisors.

igs 3a to e Intraoral situation with bonded attachments on teeth 13, 14, 23, 24, 33, 34, 35, 43, 44, 45 and hooks on teeth 16, 26, 33, 43 for Class III elastics.

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igs 4a to e ClinCheck software showing the initial intraoral situation in Class III relationship and planned IPR on mandibu-lar premolars with a maximum of 0.3 mm.

igs a to e Planned nal situation in the ClinCheck Software after 30 aligners in the maxillary arch and 60 aligners in the mandibular arch after distalization in the mandibular arch and additional IPR on mandibular premolars with a maximum of 0.3 mm.

igs a and b Non-accepted ClinCheck Software alternative with planned extraction of teeth 34, 44. The planned extraction of teeth 34, 44 counted 48 aligners with reciprocal space closure in the mandibular arch to end in a class I canine relationship. Due to the mesial movement of the mandibular molars, maxillary second molars would not have shown occlusal contact as a nal result. The mesial movement of mandibular molars as shown in this ClinCheck Software version is not predictable and needs additional skeletal anchor-age to obtain a more predictable movement. The planned treatment with extraction of mandibular rst premolars as shown in this ClinCheck Software version was not accepted, as it did not seem a valuable alternative treatment plan in this patient.

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arch for phase one and another eight aligners added in the second phase. This is rather a high number of aligners due to the complex distalization in the mandibular arch. The patient did not receive TADs, which might have improved the anchorage, but the patient was asked to wear Class III elastics at night and for 3 h during the day. To avoid a po-tentially heavy load on the TMJ, elastics with minimal force were used (0.8 Ng). Temporary anchorage devices can avoid potential load on the TMJs in Class III patients with craniomandibular disorders (CMD), and are therefore highly recommended for these patients.

Figure 1 shows the intraoral situation with skeletal Class III relationship, crowding in the maxillary and man-dibular arches with restricted maxillary arch form and re-trally inclined maxillary and mandibular incisors and a mandibular midline shift to the right at the start of treat-ment. As shown in Figure 2, the patient had severe incisor contacts on the lateral and anterior incisors. The initial orthopantomogram showed no pathologies (Fig 1). Fig-ure 2 shows the situation accordingly in the initial scan with occlusal contacts on all post eriors and non-physio-logical contacts on the incisors. There were bonded

igs 7a to e Intraoral situation after rst phase of treatment (30 maxillary and 60 mandibular aligners), with remaining anterior contact and insu cient contact of the premolars and molars.

igs 8a to e ClinCheck Software simula-tion of nal result after a further eight aligners in both arches with solving of anterior contact with IPR on mandibular anteriors (0.3 mm) and retraction and posterior extrusion.

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igs 9a to i Final extra- and intraoral situation in class I relationship and physiological overjet and overbite. Final orthopantomogram without pathological

ndings.

attachments on teeth 13, 14, 23, 24, 33, 34, 35, 43, 44, 45 and hooks on teeth 16, 26, 33, 43 for Class III elastics. The hooks and attachments shown in Figure 3 are made indi-vidually using OptiBond FL (Kerr Dental, Biberach, Ger-many) and built with the composite Enamel Plus HFO (GDF?). The initial ClinCheck Software situation (Align Technology, San Jose, California, USA) is shown in Figure 4. Figure 5 demonstrates the planned nal situation in the ClinCheck Software (Align Technology) after planned dis-talization in the mandibular arch into a full class I relation-

ship and alignment of the arches. Figure 6 shows an addi-tional treatment plan simulated in the ClinCheck Software with planned extraction of mandibular premolars, to ob-tain an alternative treatment option for the patient. The planned extraction of teeth 34 and 44 included 48 aligners with reciprocal space closure in the mandibular arch to end in a class I canine relationship. There is a great need for mesial movement of the mandibular molars. This movement, as shown in this planned version of the ClinCheck Software, is not predictable and would need

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additional skeletal anchorage to become more so. The -nal result shows the occlusal antagonist to the maxillary second molars to be missing due to the need for mesiali-sation of mandibular molars and second molars, leading in this treatment plan including extraction to a suboptimal result. Other alternatives simulated in the ClinCheck Soft-ware with the extraction of second premolars or extrac-tion of a mandibular incisor also did not lead to satisfying results. The ClinCheck situation shown in Figure 6 was therefore not accepted, as it did not seem a valuable alter-native treatment plan for this patient.

Figure 7 shows the intraoral situation after 60 weeks, with the patient changing the aligners every 7 days. There was still anterior contact and missing posterior contact, leading to the addition of eight additional aligners for n-ishing in both arches for mandibular anterior retraction with IPR and posterior extrusion for occlusal contact of all

premolars and molars (red/green contact points in the ClinCheck Pro software). Figure 8 shows the nal planned ClinCheck Software result for phase 2. Figure 9 demon-strates the nal extra- and intraoral result of the full class I relationship and physiological incisor relationship. The or-thopantomogram shows no root resorption and exhibits parallel roots.

For a radiograph to be taken, there must be medical grounds in our country for a justi cation under the Ordi-nance on the Protection of X-Ray Radiation (X-Ray Regula-tion of the Federal Republic of Germany). A radiograph is not permitted for forensic reasons alone. Documentation of the nal result is su cient in many cases, as a lateral radiograph at the close of treatment has no e ect on the

nished therapy, so an increase of information is question-able. As this patient did not undergo any surgical proced-ure, we did not use a cephalometric image in the sense of

igs 10a and b Final Scan situation with occlusal contact points. a) Compared to nal planned ClinCheck Software with same according contact point situation; b) Showing a predictable outcome of the planned treatment in the ClinCheck Software. a

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the radiograph regulation for the protection of the patients from damages by radiographs and can therefore not pres-ent it in this article.

The nal scan demonstrates the occlusal contact point situation with posterior contacts and a physiological anterior relationship without contact points, showing the according contact points in the planned result in the ClinCheck software (Fig 10). Retention was obtained with removable splints (Vivera Retainer, Align Technology) in both arches at night.

Example 2 (Team Ojima/Dan)

DiagnosisThe patient was a 27-year-old female whose chief com-plaint was a lateral open bite, leading to impaired mastica-tion and mandibular anterior crowding, as well as a desire to improve her facial pro le.

The patient’s facial con guration displayed anterior symmetry with a slight protrusion of the lower lip. In-traorally, the maxillary and mandibular midline were ap-proximately in line, central incisors displayed edge-to-edge bite, the maxillary and mandibular canines and rst molars were in Class III relationship with anterior crowding, and there was an excessive curve of Spee with a pronounced lateral open bite. Furthermore, compared with the mandib-ular dentition, the maxillary dental arch was contracted. Occlusion was unstable (Fig 12). Results of the cephalomet-ric analysis showed that the ANB was -1.1 degrees, Wits -10.0, compared with the maxilla, the mandible was further forward, and the mandibular plane was open in a skeletal Class III relationship. With regard to the incisor tooth axis, both maxillary and mandibular incisors displayed lingual inclination. A panoramic radiograph showed no patholo-

gies, the maxillary and mandibular third molars on both sides had been extracted and no pathological root resorp-tion was identi ed (Figs 13 to 15 and Table 1).

Treatment goalsWith treatment, we planned to improve the patient’s pro le through improvement of the molar relation, edge-to-edge bite of the incisors and the lateral open bite due to distali-zation in the mandibular arch.

Treatment alternativesThere were three possible ways of achieving the treatment goals. The rst was a combined orthodontic treatment op-tion including a bilateral sagittal split osteotomy (BSSO). Treatment would include a multi-bracket attachment and no extraction. Treatment time would be 24 months. The second option, while non-surgical, included extraction of all four maxillary and mandibular premolars (treatment time up to 24 months). The third option was the most ambitious: non-extraction distalization of the posterior and lateral mandibular teeth using a removable aligner (predicted treatment time of between 30 and 36 months). The patient was informed about partial improvements of her pro le with the surgery correction at a high level, and also in a mandibular amount with extraction, while the distalization alone would lead to the least improvement of the three options. After explaining the bene ts and drawbacks of each option in detail, the patient expressed interest in the option that was the least conspicuous, less invasive, non-sur-gical, non-extraction, with the lowest chance of making a large change to her pro le and the potential to nish in two years. Following a comprehensive examination of the pa-tient’s needs and treatment wishes, the third option, treat-ment with Aligner Technology’s Invisalign system13-28, was chosen.

igs 11a to c Superimposition of the ClinCheck Software showing the amount of planned distalization and retraction in the mandibular arch (blue = initial situation, white = planned outcome).

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igs 12a to h Pre-treatment facial and intraoral photographs.

igs 13a to e Pre-treatment cast models.

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Table 1 Summary of cephalometric analysis

Measurement Normal ISD Pre-treatment Post-treatment

Maxillomandibular relationships

SNA (°) 83.1 2.8 80.7 80.7

SNB (°) 79.5 2.7 81.8 81.6

ANB (°) 3.6 2.7 -1.1 -0.9

Wits appraisal (mm) -1.3 2.6 -10.0 -8.2

Vertical skeletal relationships

FMA (°) 29.0 3.6 33.7 33.3

Y-axis 65.4 5.6 65.8 65.5

Gonial angle (°) 126.6 6.0 130.9 130.9

N-ANS (mm) 55.3 2.7 48.0 48.0

ANS-Me (mm) 72.2 3.7 73.8 73.5

Dental relationships

UI to FH (°) 112.3 5.1 105.7 106.6

FMIA (°) 60.3 5.4 69.9 75.8

IMPA (°) 90.7 5.6 76.4 70.9

Interincisal angle (°) 128.0 8.0 144.1 149.3

Occulusal Pl 11.4 3.6 13.1 11.1

ig 14 Pre-treatment panoramic radiograph. ig 15 Pre-treatment lateral cephalogram.



Treatment progressionThe aligner treatment began with a three-dimensional in-traoral scan of the teeth and occlusion, followed by a treat-ment simulation using the ClinCheck Software. The treat-ment plan was decided based on this simulation (Fig 16).

The main tooth movements were as follows:1. Distalization of the mandibular molars (approximately

4 mm) to achieve a class I relation.2. Intruding of the mandibular molars to produce an ap-

propriate overbite.

3. Lateral expansion of the maxillary dental arch (approx-imately 7 mm)

Attachments were not used until 1 month after the aligner was initially inserted. Rectangular attachments were a xed to the mandibular teeth from the molars to the canines (Fig 17). After the second month, distalization of the man-dibular molars started, planned in the ClinCheck Software to move one tooth at a time in sequence, beginning with the rearmost molars.

igs 16a to e Initial situation in the ClinCheck Software.

igs 17a to e After 1 month with attachments.

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After completion of the molar distalization, the distaliza-tion of the premolars began (Figs 18 and 19). To prevent mesial drift and create an anchor for the distalization of teeth from the canines forward, TADs were installed be-tween the mandibular rst molar and second molar and elastics were used (Figs 20 to 23). Following completion of both molar and premolar distalization, distalization of the canines and incisors began, ending with an optimal over-bite of the anterior teeth. After the rst 10 months of aligner

use, minor imperfections were detected during treatment, such as a slight rotation of the mandibular canines and mandibular incisors, and we planned for extra aligners for re nement and nishing (Fig 24). Following completion of treatment, a Vivera retainer was used to retain the position.

Treatment resultsExamination of the post-treatment facial pro le photographs show that tension in the lips had improved and the lower lip

igs 18a to e Start of mandibular molar distalization and intrusion of maxillary molars.

igs 19a to e Sequential distalization of mandibular molars.

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had retracted slightly. The improvement of the initial tooth-to-tooth bite due to distalization in the mandibular arch had led to an increased overjet allowing the lips to follow the improved dental situation leading to a relaxed lip closure. The patient was satis ed with this result. Intraoral pictures showed that an appropriate overjet and overbite were achieved, maxillary and mandibular canines and molars showed a Class I relation and lateral open-bite had been perfectly improved. Post-treatment, dental arch width had

greatly increased, while molars achieved good occlusion. The nal situation is in line with the nal ClinCheck Software sim-

ulation results (Fig 25) and cephalometric analysis (Table 2). Crowding in the mandibular anterior teeth had been

relieved and, while there was slight retraction in the inter-dental papilla, it was barely noticeable and no periodontal pockets had formed. Post-treatment panoramic radio-graphs showed maintained dental parallelism, with no ob-vious root resorption in the alveolar bone (Fig 26).

igs 20a to e Placement of TADs between 36, 37 and 46, 47.

igs 21a to e Distalization of premolars with additional anchorage from TADs.

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igs 22a to e Mandibular anterior retraction.

igs 23a to e Intraoral situation with anterior retraction with Class III elastics to TADs.

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igs 24a to g Post-treatment facial and intraoral photographs.

igs 25a to e Post-treatment ClinCheck Software simulation.

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Superimposed pre- and post-treatment cephalometric analyses showed no anterior-posterior shift of the mandi-ble and a slight counter-clockwise rotation (Fig 27). Maxil-lary incisors exhibited a slight labial inclination and extru-sion and mandibular incisors exhibited labial inclination

and extrusion. The maxillary rst molars exhibited almost no change (Fig 28).

By the end of treatment, 20 stages of maxillary aligners and 61 stages of mandibular aligners had been used over 10 months. A further 6 months were added to the treat-ment, with 10 additional maxillary stages and 34 lower stages, for 16 months of treatment time in total. One-year post treatment and occlusion was stable with no change (Figs 29 to 33).

Discussion – Patient 1

As with all orthodontic treatments, several treatment alter-natives were discussed in the treatment of this young pa-tient. In order to select a medically meaningful treatment according to the criteria of evidence-based medicine and dentistry, the practitioner’s experience and the patient’s wishes should be taken into account. While planning this treatment, an orthognathic-surgical procedure was

Table 2 Dentition with measurement

Pre-treatment Post-treatment Di erence

13–23 33 mm 35 mm +2 mm

14–24 38 mm 45 mm +7 mm

16–26 57 mm 58 mm +1 mm

33–43 24 mm 28 mm +4 mm

34–44 34 mm 37 mm +3 mm

36–46 45 mm 49 mm +4 mm

ig 26 Post-treatment panoramic radiograph.

ig 28 Cephalometric superimpositions between the pre-treat-ment and Post-treatment stages: overall, maxilla and mandible.

ig 27 Post-treatment lateral cephalogram.

Palatal Plane at ANS

Mandibular Plane at MeBlack - PretreatmentRed - Posttreatment



igs 29a to c ClinCheck Software superimposition.

igs 30a to e Intraoral situation after 1-year retention.

igs 31a to g Post-treatment dental casts. Good functional occlusion can be seen from the lingual aspect.

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immediately negotiated by the patient. Although in some patients with a skeletal Class III a surgical procedure is im-perative, the non-surgical procedure was a useful alterna-tive for our patient, especially since she did not want to change her appearance.

When planning treatment, our rst question is what goal do we want to achieve and how can we create it as minimally invasively as possible. As a professional singer, it was not possible for the patient to be treated with a xed appliance due to the buccal – or, in the case of a lingual xed appliance – lingual interference. Therefore, aligner therapy was the only alternative, especially as it is signi cantly less invasive than a xed appliance therapy. The patient wore the aligners during singing without any impairment. An ex-traction therapy in the mandible was a possible alternative, but was also declined by the patient and did not seem a valuable alternative as experience has shown that distaliza-tion of mandibular posteriors with Class III elastics for an-chorage is highly predictable with the Invisalign therapy. In addition, extraction therapy is again signi cantly more in-vasive than a non-extraction therapy.

In any case where anchorage with class II elastics (distal-ization in the maxillary arch) is needed, as well as in anchor-age with class III elastics (distalization in the mandibular

arch), we bond hooks (Fig 3) to canines and molars to x elastics securely and to avoid vertical pull on the aligner. In patients with pathology of the TMJ, Class III elastics should be anchored to TADs in the mandible in order to prevent any retral mandibular positioning due to the intermaxillary elastic pull. A further advantage is the fact that the elastics or coil springs can be inserted permanently to the TADs and therefore do not require patient compliance (see patient 2). Therefore, a manual examination of the TMJs before and during the treatment, speci cally the palpation of the TMJs intra-auricular with the examiner’s little ngers, is a conditio sine qua non7.

Discussion – Patient 2

Prior to treatment, we told the patient, after examining her facial pro le and the state of her malocclusion, that she was a candidate for a surgical orthodontic procedure. The pa-tient, however, refused treatment options with extraction or mandible surgery and strongly requested an inconspic-uous corrective solution. With her desires in mind, we ex-plored several di erent orthodontic treatment options in a thorough orthodontic examination. Results showed that

ig 32 Dentition width measurement.

ig 33 Correction of Curve of Spee.



the maxillomandibular relationship exhibited a slightly re-cessed maxillary and a comparatively large mandible with an open mandibular plane, resulting in an elongated lower face. Furthermore, examination of the molar relation re-vealed that the maxillary rst molar was making occlusal contact with the second mandibular molar. Examining ANB values showed that at -1.1 degrees, the anterior-posterior relationship was hardly drastic. However, considering the occlusal relationship of the maxilla and mandible, surgical treatment was clearly the primary option.

When considering non-surgical options, Kim’s cephalo-metric analysis showed that the APDI was Class III and the ODI in open bite, and result of the CF suggested extrac-tion29. As the patient had refused extraction treatment, we moved forward with a maxillary-mandibular non-extraction treatment plan to relieve crowding in the mandibular anter-ior teeth and improve molar relation through distalization of the mandibular dentition. The treatment plan called for at least a 4 mm distalization of the mandibular molars. Ac-cording to the literature we reviewed on both maxillary and mandibular molar distalization, this was an unprecedent-edly large distance.

Since its release, the modern aligner system has gone through various improvements, evolving to expand the range of possible treatments to a wider variety of compli-cated malocclusion. However, compared with the long his-tory of edgewise methods, it would be challenging to pre-dict the safe and accurate completion of this treatment with a high degree of certainty. Furthermore, with molar distalization in cases of open bite, in order to avoid the molar raising wedge e ect – considered by us to be the key to the success of this treatment – we decided that rather than an en masse movement using TADs and extraoral force, we would opt for a more time-consuming, but safer treatment plan, with individual tooth movements that would allow a greater degree of control. We explained to the patient that treatment with aligners could take up to 3 years and that she should not expect a drastic improve-ment in her facial pro le. The patient agreed to use as-sistive TADs in order to prevent mesial movement of the distalized teeth. We were especially concerned with the distalization of the rst and second mandibular molars and, after distalization of the second molar – half of the total movement distance – we began distalization of the

rst molar. When we began retraction of the premolars, in

order to prevent mesial movement of the molars moved thus far, we had implanted TADs between the rst and second molars, which had unfortunately come loose mid-treatment on the right side. These were reattached to the distal side of the second molar.

No orthodontic treatment can allow unlimited move-ment of teeth. Studies have shown this to be especially true in the case of the mandibular incisors, due to the shape and thickness of the symphysis30. In this case the symphysis was especially thin, and it was suggested that moving lower anteriors in this edge-to-edge bite lingually would be chal-lenging and there was a limit to how much lingual move-ment was possible in the incisors. Actual treatment results show that even though mandibular incisors exhibit lingual inclination and that the alveolar bone displayed similar cur-vature, no root exposure or resorption was detected.

When treating overbite, our main goal is to increase the depth of the anterior occlusal bite. Schupp has reported that in his aligner treatments he has used attachments to achieve not relative, but absolute, extrusion. With Kim using the edgewise method (MEAW), he reported that it is neces-sary to change the occlusion plane31,32. Results from the present study also indicate absolute extrusion of the anter-ior teeth and inclination of the occlusal plane.

In our plan to move teeth with aligners, movements can be roughly divided into distalization of the mandibular and the posterior teeth, followed by retraction of the incisors. During each clinical visit, we checked to see whether or not tooth movement was consistent with the ClinCheck Soft-ware simulation to ensure su cient adaptation of each aligner33-38. As a result, the number of aligners and the overall treatment time naturally increased. The original treatment plan called for 61 stages, with maximum move-ment of a single stage of 0.25 mm over a 2-week period. This equated to treatment time exceeding 30 months. To reduce the period of treatment, we decided to use Ortho-Accel’s AcceleDent, an accelerated orthodontic device, which we have used repeatedly to achieve e ective re-sults39-44.

There is controversy about the e ectiveness of this de-vice. It is thought that e ectiveness with multi-bracket sys-tems depends on a number of factors, including the type of brackets, wire size and shape, and the method of wire liga-tion. It is di cult to say that aligners, a wireless option that instead cover the teeth to move them, is not a ected by


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similar restrictions, and thus it is impossible to say that aligners are the best t for the device.

Even so, by using an accelerated orthodontic device, not only is treatment time shorter and aligner t improved, but the pain and discomfort that usually accompanies the initial insertion of a new aligner stage is also decreased. The ben-e ts of accelerated orthodontics extend beyond the ortho-dontist to the patient as well.

Using AcceleDent, we were able to reduce the previous 2-week aligner change period to 5 days, reducing the initial treatment estimate of 36 months to a mere 16 months. Due to the lack of cases with identical conditions it is di cult to make a simple comparison, but comparing other cases treated with multi-bracket systems vs aligners with TADs, this reduction in treatment time seems signi cant. Further-more, the ability to monitor tooth movement mid-treat-ment through comparison with the simulation in the ClinCheck Software, reduces lost motion due to insu cient adaptation between aligners and teeth. The results of the tooth movement in this study as planned are evidence of the validity of the treatment plan.

Examining the results of this treatment, we can see that tension has been relieved from the mentum region, creat-ing a truly natural looking lip structure with a harmonious E-line. The patient was able to achieve favourable improve-ment in her facial pro le without surgery and was quite satis ed.

Intraorally, edge-to-edge occlusion of the incisors and the lateral overbite has been completely improved. There is absolute extrusion of both the maxillary and mandibular incisors, the functional occlusal plane from the rst molars is smaller in the direction of closure, and the use of the upright MEAW technique to achieve similar results as with a combination of vertical elastics is certainly interesting.

It can be surmised that the mechanism of the extrusion of the mandibular incisors was the traction of the aligner by the TADs, intrusion and uprighting of the mandibular mo-lars led to a reduction of the occlusal plane angle, and the extrusion and rotation of the anterior teeth.

Moving forward, it is our plan to increase the number of treatments of similar cases to increase the predictability of tooth movement when using aligners and other additional devices.

Conclusion

In this study, favourable occlusion was achieved in Class III patients using aligners to perform a non-extraction and non-surgical treatment with distalization in the mandible with and without temporary anchorage devices. According to the rst patient example, treatment time can be short-ened by 50% with an aligner change every 7 days. Further-more, the use of an accelerated orthodontic device enabled a further reduction to a 5-day change of aligner wear for the second patient.

References1. Yazdani, AA. Transparent aligners: An invisible approach to correct

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Documents

Werner Schupp, Julia Haubrich, Kenji Ojima, Chisato Dan ... · dibular molar distalization. Example 1 (Team Schupp/Haubrich) Diagnosis The 26-year old female patient presented herself